Unit 5: 1500 Claim Form Guidelines

Top of Form

Carrier Block

Report name and address in the center of the open space. Do not report above Item #1a (this is where Highmark prints the claim number).

Please do not staple over the Quick Response (QR) code symbol. Highmark’s scanners read the symbol to identify that the 1500 Claim Form is the 02/12 version.

1

Type of Health Insurance
Coverage

For Highmark products, place an X in the "Other" box.

1a

Insured’s ID Number

Enter insured's identification number exactly as shown on the insured's identification card. Be sure to include any alpha prefixes.

2

Patient’s Name

Enter the patient's full last name, first name, and middle initial. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

If the patient uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

3

Patient’s Birth Date,
Sex

Enter the patient's 8-digit birth date (MM|DD|YYYY). Enter an X in the correct box to indicate sex of the patient. Only one box can be marked. If gender is unknown, leave blank.

4

Insured’s Name

Enter the insured's full last name, first name, and middle initial. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name. Do not use terms such as “Self” or “Same” if the patient is also the Insured.

If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

5

Patient’s Address

Enter the patient's mailing address. This field has 3 lines — the first line is for the street address; the second line, the city and state; and the third line, the ZIP Code. “Patient’s Telephone” is not used in processing and is not required by Highmark.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP Code. Enter the 9-digit ZIP Code without the hyphen.

6

Patient Relationship to Insured

Enter an X in the correct box to indicate the patient's relationship to insured. Only one box can be marked.

7

Insured’s Address

Enter the insured's address. If Item #4 is completed, then this field should also be completed. This field has 3 lines — the first line is for the street address; the second line, the city and state; and the third line, the ZIP Code. “Insured’s Telephone” is not used in processing and is not required by Highmark.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP Code. Enter the 9-digit ZIP Code without the hyphen.

8

Reserved for NUCC
Use

Highmark does not need this information to adjudicate the claim. Leave blank.

9

Other Insured’s Name

If Item #11d is marked, complete fields 9 and 9a-d; otherwise leave blank. When additional group health coverage exists, enter other insured’s full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in Item #2. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

9a

Other Insured’s Policy or Group Number

Enter the policy or group number of the other insured.

9b

Reserved for NUCC
Use

Highmark does not need this information to adjudicate the claim. Leave blank.

9c

Reserved for NUCC
Use

Highmark does not need this information to adjudicate the claim. Leave blank.

9d

Insurance Plan Name or Program Name

Enter the other insured's insurance plan or program name.

10a,b,c

Is Patient’s Condition Related to:

When appropriate, enter an X in the correct box to indicate whether one or more of the services described in Item #24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked. The 2-letter state code (e.g., PA, DE) must be shown if "YES" is marked in Item #10b for "Auto Accident." Any item marked "YES" indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance.

10d

Claim Codes (Designated by
NUCC)

Highmark requires the sub-set of Condition Codes approved by the NUCC in this field, when applicable. When reporting more than one code, enter three blank spaces and then the next code. The Condition Codes approved for use on the 1500 Claim Form are available at http://www.nucc.org under Code Sets.

11

Insured’s Policy, Group, or FECA Number

Enter the insured's policy or group number as it appears on the insured's health care identification card. Do not use a hyphen or space as a separator within the policy or group number. If Item #4 is completed, then this box should also be completed.

11a

Insured’s Date of Birth, Sex

Enter the 8-digit date of birth (MM|DD|YYYY) of the insured and an X to indicate the sex of the insured. Only one box can be marked. If gender is unknown, leave blank.

11b

Other Claim ID
(Designated By NUCC)

Highmark does not need this information to adjudicate the claim. Leave blank.

11c

Insurance Plan Name or Program Name

Enter the insurance plan or program name of the insured.

11d

Is There Another Health Benefit Plan?

When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9a, and 9d. Only one box can be marked.

12

Patient’s or Authorized Person’s Signature

Highmark does not need this information to adjudicate the claim.

The “Patient’s or Authorized Person’s Signature” indicates there is an authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim. You may report "Signature on File," "SOF," or a legal signature in this box. If you obtain a legal signature, (1) be sure the name is contained inside this box so it does not interfere with data you report in other boxes, and (2) enter the date signed in 6-digit format (MM|DD|YY). If there is no signature on file, leave blank or enter "No Signature on File."

13

Insured’s or Authorized Person’s Signature

Highmark does not need this information to adjudicate the claim.

The “Insured’s or Authorized Person’s Signature” indicates that there is a signature on file authorizing payment of medical benefits. You may report "Signature on File," "SOF," or a legal signature in this box. If you obtain a legal signature, (1) be sure the name is contained inside this box so it does not interfere with data you report in other boxes, and (2) enter the date signed in 6-digit format (MM|DD|YY). If there is no signature on file, leave blank or enter "No Signature on File."

14

Date of Current Illness, Injury, or Pregnancy (LMP)

Enter the 6-digit (MM|DD|YY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Be sure to complete this field when services were performed as a result of accident or injury.

Enter the applicable qualifier to identify which date is being reported:

• 431 – Onset of Current Symptoms or Illness
• 484 – Last Menstrual Period

Be sure to enter the date and qualifier in the correct fields. The qualifier is entered to the right of the vertical, dotted line.

DE Only:

For physical, occupational, and speech therapy services: This box must be completed if the Highmark Delaware member has a per condition benefit.

15

Other Date

Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit format (MM|DD|YY). (Previous pregnancies are not a similar illness.) Leave blank if unknown.
Enter the applicable qualifier to identify which date is being reported.

• 454 – Initial Treatment
• 304 – Latest Visit or Consultation
• 453 – Acute Manifestation of a Chronic Condition
• 439 – Accident
• 455 – Last X-ray
• 471 – Prescription
• 090 – Report Start (Assumed Care Date)
• 091 – Report End (Relinquished Care Date)
• 444 – First Visit or Consultation

Be sure to enter the date and qualifier in the correct fields. The qualifier is entered between the left-hand set of vertical, dotted lines.

DE Only:

For physical, occupational, and speech therapy services: Please provide date if applicable.

16

Dates Patient Unable to Work in Current Occupation

If the patient is employed and is unable to work in current occupation, a 6-digit (MM|DD|YY) date must be shown for the "from-to" dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

17

Name of Referring
Provider or Other Source

Enter the name (first name, middle initial, last name) and credentials of the professional who referred or ordered the service(s) or supply(s) on the claim. Do not use periods or commas. A hyphen can be used for hyphenated names.

If multiple providers are involved, enter one provider only using the following priority order:

1. Referring Provider
2. Ordering Provider
3. Supervising Provider

Enter the applicable qualifier to identify which provider is being reported.

• DN – Referring Provider
• DK – Ordering Provider
• DQ – Supervising Provider

Enter the qualifier to the left of the vertical, dotted line.

17a

Other ID#

When the Referring Provider’s National Provider Identifier (NPI) is associated with more than one Highmark-assigned provider number, the Provider Taxonomy Code correlating to the contracted specialty must be submitted in addition to the NPI. This enables the accurate application of the provider’s contractual business arrangements with Highmark.  The PXC Provider Taxonomy qualifier is reported in the qualifier field to the immediate right of the box containing “17a,” followed by the referring Provider’s taxonomy code.

17b

NPI#

Enter the NPI number of the referring provider, ordering provider, or other source in Item #17b.

18

Hospitalization Dates
Related to Current Services

Enter the inpatient 6-digit (MM|DD|YY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization (inpatient services only).

19

Additional Claim
Information (Designated By NUCC)

Highmark does not need this information to adjudicate the claim. Leave blank.

20

Outside Lab?$Charges

Highmark does not need this information to adjudicate the claim. Leave blank.

21

Diagnosis or Nature of Illness or Injury

The “ICD Indicator” identifies the version of the ICD code set being reported. Enter 0 (zero) for ICD-10-CM.

Enter the indicator between the vertical, dotted lines in the upper right-hand area of the field.

***************

In A – L, enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 diagnosis codes. Use the highest level of specificity. Enter the codes left-justified on each line. Do not include the decimal point within the diagnosis code. Relate lines A – L to the lines of service in 24E by the letter of the line.

** Do not provide narrative description in this field. **
Highmark will accept only ICD-10-CM diagnosis codes.
***************

Please see instructions regarding Federal Employee Program (FEP) claims and anesthesia reporting in Chapter 6.4: Professional (1500/837P) Reporting Tips.

22

Resubmission

When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field.

• 7 – Replacement of prior claim
• 8 – Void/cancel of prior claim

List the original reference number for resubmitted claims.

23

Prior Authorization
Number

For ambulance services, use this block to report the ZIP Code of the Point of Origin. (The 9-digit ZIP+4 Code is not required for the Point of Origin but will be accepted if reported.) Ambulance providers who submit paper claims for non-emergent ambulance transports must attach a PMNC (Physician’s Medical Necessity Certification) form to the claim.

24

Supplemental information can only be entered with a corresponding, completed service line. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service.

The following types of supplemental information and their qualifiers can be entered in the shaded lines of Boxes 24A through 24H:

Qualifier

Type of Information

7 Anesthesia information

Report the surgical HCPC procedure code when a ‘Not Otherwise Specified’ or ‘Not Otherwise Classified’ anesthesia service is reported. A complete description of the surgical service performed can be used in lieu of a surgical HCPC code or if the only applicable surgical procedure code is an NOC.

ZZ Narrative description of unspecified code

Narrative description of unspecified code.

N4 National Drug Codes (NDC)

National Drug Codes (NDC) for drugs: Report the qualifier, N4, prior to the 11-digit* NDC, e.g., N499999999999.

To enter supplemental information in the shaded area, begin at Box 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the number/code/information. Do not enter hyphens or spaces within the number/code.

*Many NDCs are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs from a 10-digit to 11-digit format requires a strategically placed zero, dependent on the 10-digit format. For more information, refer to the section titled Reporting National Drug Codes in Chapter 6.2: General Claim Submission Guidelines.

24A

Date(s) of Service

Enter date(s) of service, from and to, in 6-digit format (MM|DD|YY). If one date of service only, enter that date under "From." Leave "To" blank. If grouping services, you may range date if the place of service, procedure code, charges, and individual provider for each line is identical for that service line. Grouping is allowed only for services on consecutive days. The number of days must correspond to the number of units in Item #24G. An exception to this is prolonged detention care. Do not range date these services even when performed on consecutive days.

24B

Place of Service

Enter the appropriate 2-digit code from the Place of Service Code list for each item used or service performed. The Place of Service Codes are available at:
https://www.cms.gov/place-of-service-codes

24C

EMG

Highmark does not need this information to adjudicate the claim. Leave blank.

24D

Procedures, Services, or Supplies

Enter the CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of one procedure code and up to four 2-character modifiers. The specific procedure code(s) must be shown without a narrative description.

24E

Diagnosis Pointer

In 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable.

Enter letters left justified in the field. Do not use commas between the letters; hyphens can be used for ranges of multiple letters. This field allows for the entry of 4 characters in the unshaded area.

Diagnosis codes must be entered in Item Number 21 only. Do not enter them in 24E.

24F

$ Charges

Enter the charge for each listed service. Enter the number right-justified in the left-hand area of the field. Do not use commas or dollar signs when reporting the dollar amount. Do not report negative dollar amounts. Enter 00 in the right-hand area of the field if the amount is a whole number.

24G

Days or Units

Enter the number of days, units, or minutes. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. When required by payers to provide the NDC units in addition to the HCPCS units, enter the applicable NDC units' qualifier and related units in the shaded line following the NDC qualifier and code. The following qualifiers are to be used when reporting an NDC quantity. Report the qualifier prior to the quantity, e.g., UN2.

F2 International Unit

ML Milliliter

GR Gram

UN Unit

24H

EPSDT/Family Plan

Highmark does not need this information to adjudicate the claim. Leave blank.

24I

ID Qualifier

The ‘NPI’ ID qualifier is pre-populated in the non-shaded area of Item #24I. (The Rendering Provider’s NPI is reported in the non-shaded area of Item #24J.)

When the Rendering Provider’s National Provider Identifier (NPI) is associated with more than one Highmark-assigned provider number, the Provider Taxonomy Code correlating to the contracted specialty must be submitted in addition to the NPI. This enables the accurate application of the provider’s contractual business arrangements with Highmark. When required to report the Rendering Provider’s Taxonomy Code, enter the PXC Provider Taxonomy qualifier in the shaded area of Item #24I.

Note: In most instances, the 3-character PXC qualifier can be printed within Item #24I. If the PXC qualifier runs into Item #24J, our Optical Character Recognition (OCR) scanner will still capture the qualifier and provider taxonomy correctly since 24I and 24J are read as one field.

24J

Rendering Provider ID#

The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. Report the provider’s information in Item Numbers 24I and 24J only when different from data recorded in Item Numbers 33a and 33b.

In other words, when you report a billing provider (e.g., assignment account) in Item #33, you must report the rendering/performing provider information in Item #24I and Item #24J. Enter the Rendering Provider’s NPI number in the non-shaded area of Item #24J.

Note: In the case where a substitute provider (locum tenens) was used, the regular physician on whose behalf the services were furnished by a substitute is reported as the rendering provider. The HCPCS modifier Q6 is entered after the procedure code(s) in Item 24D to indicate that the services were provided by a substitute provider.

When the Rendering Provider’s National Provider Identifier (NPI) is associated with more than one Highmark-assigned provider number, the Provider Taxonomy Code correlating to the contracted specialty must be submitted in addition to the NPI. This enables the accurate application of the provider’s contractual business arrangements with Highmark. In the shaded area of Item #24J, enter the Rendering Provider’s Taxonomy Code when required.

25

Federal Tax ID Number

Enter the federal tax ID (employer identification number) or Social Security number. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked. This must be the tax ID which correlates to the billing provider reported in Item #33.

26

Patient’s Account No.

Optional. Highmark does not require this number for processing; however, we can reference this number when contacting your office for additional information.

27

Accept Assignment?

Enter an X in the correct box. Only one box can be marked.
Note: This box is required for government claims only.

28

Total Charge

Enter total charges for the services (i.e., total of all charges in column 24F). Enter amount right justified in the left-hand area of the field. Do not use commas or dollar signs when reporting dollar amounts. Do not report negative dollar amounts.
Enter 00 in the right-hand area if the amount is a whole number.

29

Amount Paid

Enter total amount the patient or other payers paid on the covered services only. Enter number right justified in the dollar area of the field. Do not use commas or dollar signs when reporting dollar amounts. Do not report negative dollar amounts. Enter 00 in the cents area if the amount is a whole number.

30

Reserved For NUCC Use

Highmark does not need this information to adjudicate the claim. Leave blank.

31

Signature of Physician or
Supplier Including Degrees or Credentials

This field must be completed on all claims to affirm that the reported services were performed by the provider, or performed under the provider's personal supervision. The name of the individual performing the service on the claim must be entered. The name may be computer printed or typed. Simply reporting the name of the group is insufficient.

32

Service Facility
Location Information

Enter the name, address, city, state, and ZIP Code of the location where the services were rendered. The full nine digits of the ZIP+4 Code must be reported. Enter the 9-digit ZIP Code without the hyphen. The use of zeros (0000) or spaces for the last four digits of the ZIP+4 Code is not valid.

Enter the name and address information in the following format:

1st Line – Name
2nd Line – Address
3rd Line – City, State and ZIP+4 Code

Note: A physical street address must be reported for the Service Facility Location — a P.O. Box or lock box will not be accepted.

Highmark requires the Service Facility Location when the service was performed at a secondary location and the provider’s primary location was reported in Item #33. Highmark always requires the Service Facility Location when the Place of Service reported in Item #24B is one of the following:

21 – Inpatient Hospital
22 – Outpatient Hospital
23 – Emergency Room – Hospital
31 – Skilled Nursing Facility
32 – Nursing Facility
51 – Inpatient Psychiatric Facility
61 – Comprehensive Inpatient Rehabilitation Facility

32a

Service Facility – NPI#

Enter the NPI number of the service facility location.

32b

Service Facility – Other ID#

When the National Provider Identifier (NPI) is associated with more than one Highmark-assigned provider number, the Provider Taxonomy Code correlating to the contracted specialty must be submitted in addition to the NPI. This enables the accurate application of the provider’s contractual business arrangements with Highmark.
Enter the PXC Provider Taxonomy qualifier followed by the Provider’s Taxonomy Code when required.

33

Billing Provider Info & PH #

Item #33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter the billing provider's name, address, ZIP Code, and telephone number. The full nine digits of the ZIP+4 Code must be reported. Enter the 9-digit ZIP Code without the hyphen. The use of zeros (0000) or spaces for the last four digits of the ZIP+4 code is not valid.

The telephone number is to be entered in the area to the right of the box title. Enter the name and address information in the following format:

1st Line – Name
2nd Line – Address
3rd Line – City, State and ZIP+4 Code

Note: A physical street address must be reported for the Billing Provider — a P.O. Box or lock box will not be accepted.

33a

Billing Provider - NPI#

Enter the NPI number of the billing provider reported in Item #33.

33b

Billing Provider - Other ID#

When the Billing Provider’s National Provider Identifier (NPI) is associated with more than one Highmark-assigned provider number, the Provider Taxonomy Code correlating to the contracted specialty must be submitted in addition to the NPI. This enables the accurate application of the provider’s contractual business arrangements with Highmark. Enter the PXC qualifier followed by the Provider’s Taxonomy Code when required.

B5606

In order to process the claim, additional information is required. Please resubmit the claim with a prescription for this service. Electronically enabled providers should resubmit electronically.

P5039

In order to process this claim, additional information is required. The claim should be resubmitted with a valid modifier and associated number of services rendered. Electronically enabled providers should resubmit electronically.

P5040

The patient’s coverage does not provide for this service in the place of treatment reported. Therefore, no payment can be made.

P5010

The procedure code reported is not appropriate for the patient’s age. Please resubmit claim with verification of the patient’s age and/or a corrected procedure code. Electronically enabled providers should resubmit electronically.

P5011

The procedure code reported is not appropriate for the patient’s age. Please resubmit claim with verification of the patient’s age and/or a corrected procedure code. Electronically enabled providers should resubmit electronically.

P5012

The patient’s sex is invalid for the reported procedure. Please resubmit the claim with verification of the patient’s sex and/or a corrected procedure code or a complete description of service. Electronically enabled providers should resubmit electronically.